Faculty Bibliography

BACKGROUND:Transvenous lead extractions (TLEs) have increased in number due to an increased prevalence of cardiac implantable devices. Bleeding complications associated with TLEs can be catastrophic, and many institutions order blood components to be available in the procedure room. There are few studies supporting or refuting this practice. We evaluated transfusion rates for TLEs at a single, high-volume center to assess the need for having blood in the procedure room. STUDY DESIGN AND METHODS/METHODS:Patients undergoing TLEs from April 2010 to February 2019 were identified from our institutional database. The percentage of patients transfused intraoperatively, the number of units transfused, and the reasons for transfusion were determined from the database and by manual chart review. RESULTS:A total of 473 patients underwent a TLE during this time frame. Of these, only 17 patients (3.6%) received a red blood cell (RBC) transfusion. Ten of the 17 patients received RBCs secondary to preoperative anemia. Of the remaining seven patients, only four patients received more than 2 RBC units, and only one received more than 10 RBC units. No patient received more than 2 RBC units or any plasma or platelets in the past 4 years. CONCLUSION/CONCLUSIONS:Due to improvements in procedural techniques, advent of accessible remote blood allocation systems, and changes in transfusion practice (e.g., electronic crossmatch), routinely having blood components in the procedure room for every TLE may be an outdated practice for high-volume centers.

BACKGROUND:Pacemaker battery depletion triggers alert for replacement notification and results in automatic reprogramming which has been shown to be associated with relevant cardio-respiratory symptoms and adverse clinical events. OBJECTIVE:Determine if electrocardiogram (ECG) pacing features may be predictive of pacemaker battery depletion and clinical risk. METHODS:This is an ECG sub-study of a cohort analysis of 298 subjects referred for pacemaker generator replacement from 2006 - 2017. Electronic medical record review was performed; clinical, ECG, and pacemaker characteristics were abstracted. We applied two ECG prediction rules for pacemaker battery depletion that are relevant to all major pacemaker manufacturers except Boston Scientific and MicroPort; 1. Atrial pacing not at a multiple of ten and 2. Non-synchronous ventricular pacing not at a multiple of ten, to determine diagnostic sensitivity, specificity and risk in applicable ECG subjects. RESULTS:We excluded 32 subjects not at replacement notification or duplicate surgeries. Overall, 176/266 subjects (66.2%) demonstrated atrial pacing or non-synchronous ventricular pacing on pre-operative ECG. When utilizing both rules, 139/176 pre-operative ECGs and 12/163 post-operative ECGs met criteria for battery depletion yielding reasonable sensitivity (79.0%), high specificity (92.6%), and a positive likelihood ratio of 11.6:1. These rules were associated with significant increase in cardio-respiratory symptoms (p < 0.001) and adverse clinical events (p < 0.025). CONCLUSIONS:The "Rules of Ten" provided reasonable sensitivity and specificity for detecting replacement notification in pacemaker subjects with an applicable ECG. This ECG tool may help clinicians identify most patients with pacemaker battery depletion at significant clinical risk. This article is protected by copyright. All rights reserved.

BACKGROUND:An internal risk stratification algorithm was developed to decrease the risk of major adverse cardiac events (MACEs) during lead extractions (LEs). OBJECTIVE:To report upon the impact of a risk stratification algorithm (RISE Protocol) on outcomes of LEs in a high volume center. METHODS:coronary sinus lead. During prospective evaluation of the RISE protocol, "High risk" LEs were performed in an operating room (OR) or hybrid laboratory with cardiac anesthesiologist, operating room nursing team and perfusionist in the room and a cardiac surgeon on the premises. "Low risk" LEs were performed in the electrophysiology (EP) laboratory with anesthesia provided by EP nursing team. The pre-intervention (Pre-RISE) and post-intervention (Post-RISE) group spanned 19 and 40 months and consisted of 449 (632 leads) and 751 patients (1055 leads) respectively. Primary outcome of MACEs in the two groups was compared. RESULTS:Protocol compliance was 100%. Primary outcome of MACEs occurred in 15 patients (3.34 %) before and 12 (1.6 %) after implementation of the RISE protocol (p = 0.04). CONCLUSION/CONCLUSIONS:RISE identified a low risk group where minimal resources are needed, and allowed for rapid intervention in the high-risk group that reduced the consequences of MACEs. This article is protected by copyright. All rights reserved.

BACKGROUND:Pacemaker patients experience battery depletion and activate their alert for replacement notification. Automatic reprogramming at replacement notification can result in loss of rate response and atrio-ventricular (AV) synchrony. OBJECTIVE:Determine if relevant symptoms or clinical events may be associated with automatic reprogramming at replacement notification. METHODS:Electronic medical record review was undertaken for 298 patients referred for pacemaker generator replacement. Primary endpoints were symptoms or clinical events during replacement notification period. RESULTS:Following elimination of duplicate pacemaker replacements (n = 12), "near-replacement notification" or "recalled" (n = 15), and pacemakers at "end of life" (n = 5), 266 subjects were included. Three distinct reprogramming cohorts were identified; those with no change (control) in pacing mode (n = 46), those with loss of rate response (n = 154), and those with loss of AV synchrony ± rate response (n = 66). In total, 83 subjects (31.2%) had symptoms with significant differences seen between groups (control - 4.3%, loss of rate response - 26.0%, loss of AV synchrony ± rate response - 62.1%, p < 0.001). Overall, 28 subjects (10.5%) experienced clinical events with significant differences seen between groups (control - 0.0%, loss of rate response - 6.5%, loss of AV synchrony ± rate response - 27.3%, p < 0.001). CONCLUSIONS:Automatic reprogramming at replacement notification was associated with significant symptoms in 26% of those who lost rate response and in 62% of those who lost AV synchrony ± rate response. Additionally, 27% of the latter cohort required non-elective clinical care.

Although definitive therapy for infected cardiac implantable electronic device systems requires removal of all hardware in the infected areas with extraction of intravascular components as well, there are situations where extraction is not available or appropriate. Palliative procedures and chronic suppressive antibiotics may be used in these cases. There are also options that may in some cases result in long-term freedom from infection.